Gaps In the Mental Health Care Pathway: Assessing Access and Utilization of Integrated Behavioral Health In Community Primary Care Clinics

Background and Purpose: Mental illness affects more than one in five U.S. adults, yet the unmet need for treatment remains high. Barriers to mental health care include fragmented systems, poor communication, poorly defined referral pathways, which contribute to referral failures and delays in follow-up. Although efforts have been made to integrate mental health into primary care, evidence remains limited regarding factors associated with receiving referrals and psychiatric assessments. This study examined the association between client-level predictors and referral and psychiatric assessment following a first positive PHQ-9 or GAD-7 screening in community primary care clinics offering integrated behavioral health services in Minnesota.

Methods: We conducted a retrospective observational study using de-identified electronic health record data from 2018 to 2024, extracted from the community primary care clinics that offer Integrated Behavioral Health services. The analytic sample included adult clients with a documented first positive PHQ-9 or GAD-7 screening (scores over 10) and follow-up service data. Outcomes were (1) any referral within 90 days after the first positive screening and (2) any psychiatric diagnostic assessment within 90 days after the first positive screening. Predictors included race and ethnicity, gender, older adult status (60 years and older), and state-level Area Deprivation Index (ADI) category. Descriptive analyses and multivariable logistic regression were conducted to evaluate the association between predictors and the adjusted odds ratio (aOR) for receiving referral and assessment outcomes following positive screening.

Results: The sample included 22,908 adults with a first positive PHQ-9 or GAD-7 screening. Overall, 4,669 patients (20.38%) had a documented referral within 90 days, and 2,039 (8.90%) had a psychiatric diagnostic assessment within 90 days. For referrals, Hispanic or Latino (aOR = 1.36, 95% CI [1.15, 1.62]), Black non-Hispanic (aOR = 1.31, 95% CI [1.16, 1.47]), and Asian non-Hispanic patients (aOR = 1.20, 95% CI [1.03, 1.39]) had higher odds than White non-Hispanic patients. Female (aOR = 0.88, 95% CI [0.82, 0.95]), age 60 years and older (OR = 0.54, 95% CI [0.49, 0.59]), medium deprivation (aOR = 0.91, 95% CI [0.84, 0.99]), and high deprivation (OR = 0.78, 95% CI [0.70, 0.86]) were associated with lower referral odds. For psychiatric assessment, Hispanic or Latino patients had higher odds than White non-Hispanic patients (aOR = 1.29, 95% CI [1.02, 1.63]), whereas Black non-Hispanic patients (aOR = 0.78, 95% CI [0.64, 0.94]), adults aged 60 years and older (aOR = 0.38, 95% CI [0.33, 0.45]), and those residing in medium- (aOR = 0.75, 95% CI [0.67, 0.84]) and high-deprivation areas (aOR = 0.47, 95% CI [0.40, 0.54]) had lower odds of assessment.

Conclusions and Implications: Study results indicated substantial attrition along the care pathway, even in integrated behavioral health settings. Findings suggest quality of care inequities based on race and ethnicity, age, and socio-economic status, leading to less access to follow-up care, particularly at the assessment stage. These results underscore the need for targeted strategies to strengthen follow-through after positive screening, improving equity in access for Black and Asian populations, older adults, and clients living in more deprived communities.